Chapter 1 Professional Issues

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1

Why are Sonographers professionals

Specialized knowledge & educational preparation

2

Therapeutic Ultrasound

High energy
low frequency
Used for internal deep heating
- increased blood supply
- promotes healing
- Pain killing effect
- Promotes normal funtion

3

Diagnostic Ultrasound

Low energy
High Frequency
Uses the reflected sound and interprets that soun in a graphical format.

4

Probemanship

Prevent injury

5

sector

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6

vector

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7

linear

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8

curved linear

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9

scan planes

Know it

10

Erect Position

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Used when doing RUQ and looking at the gall bladder

11

semi-erect

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Halfway between sitting straight and lying

12

supine

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flat on one's back, face upward, facing upward

exams
RUQ
*liver
*pancreas
* aorta
*part of gallbladder
carotid
transabdominal pelvis

13

prone

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not usde very much except on baby kidneys and renal core biopsies

14

lithotomy

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exams
transvaginal
pelic exams

15

trenddelenburg

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16

cephalic

toward the head

17

caudal

toward the feet

18

AP

Anterior/Posterior

entering anterior and exiting posterior

19

PA

Posterior/Anterior

entering posterior and exiting anterior

20

left posterior oblique

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left posterior surface is touching table

21

right posterior oblique

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right posterior surface is touching table

exams
left kidney

22

left anterior oblique

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left anterior surface is touching table

Exams:
gallbladder

23

right anterior oblique

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right anterior surface is touching table

Exams:
gallbladder

24

Transducer Movements

Sliding

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moving the probe face along the surface of the skin

either cephalic/caudal or lateral/medial

25

Transducer Movements

rocking

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Rocking also called heel/toe angling the probe along the long axis of the beam

26

Transducer Movements

rotating

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twisting the probe to align the beam with the desired structure

27

Transducer Movements

angling

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sweeping the beam along its axis, side to side. In long view you would angle lateral/medial

28

RUQ Exam

Clean room
*introductions
*review what exams have been ordered
*confirm the preparation
*give dressing intructions
*enter patient info
*set parameters
*select transducer
*have your sheets/towels ready
*do as much paperwork as possible - Get History

29

Clinical History

Determine CHIEF complaint
Document associated complaints

30

History Sacred 7

Localization
Chronology
Quality
Severity
Onset
Aggravating or Alleviating circumstances
Associated Manifestation

31

Localization

Define an exact area
RUQ or RLQ

*most exams are RUQ

32

Chronology

Duration

Frequency

Course

33

Quality

Acute - sudden

Chronic - persistent

Descriptive terms help - burning, throbbing, dull, sharp, cutting, stabbing, aching, radiating, crushing

34

Severity

Use 1 - 10 scale

35

Onset

Try to establish pattern of occurance
are they predictable events
* walking
* sitting
* laying
* gallstone - sick after eating fat

36

Aggravating or Alleviating circumstances

What makes it better?
What makes it worse?

37

Associated Manifestation

Are other systems somehow related?

38

Patient Medical Hx

previous disease
ETOH intake
personal cancer hx
Family hx

39

Present Medication

Ulcer meds
anti-depressants
anti-arrhythmic agents
cholesterol lowing agents

40

SGOT

7-40 U/L Conventional/ 4-20 SI

elevated indicates liver disease

Serum glutamic oxaloacetic transaminase, an enzyme that is normally present in liver and heart cells. SGOT is released into blood when the liver or heart is damaged. The blood SGOT levels are thus elevated with liver damage

41

SGPT

10-40 U/L Conventional/ 5-20 SI

elevated indicates liver disease

Serum glutamic pyruvic transaminase, an enzyme that is normally present in liver and heart cells. SGPT is released into blood when the liver or heart are damaged. The blood SGPT levels are thus elevated with liver damage

42

Alkaline Phosphatase

30-115 mu/ml

elevated indicates liver disease / biliary obstruction

An enzyme that liberates phosphate under alkaline conditions and is made in liver, bone, and other tissues. Alkaline phosphatase can be measured in a routine blood test. Abnormally high serum levels of alkaline phosphatase may indicate bone disease, liver disease, or bile duct obstruction.

43

Total bilirubin

.1-1.2 mg/dl C or 1.7-20.5 mmol/L SI

elevated anemia

44

Direct Bilirubin

.1-.2 mg/dl C or 1.7-3.4 mmol/L SI

elevated Biliary obstruction

45

Indirect Bilirubin

.1-1 mg/dl C or 1.7-17.1 mmol/L SI

elevated with increased RBC destruction/Hemolysis

46

BUN

Blood Urea Nitrogen

10-20 mg/dl C or 3.6-7.2 mmol/L SI

elevated in kidney failure
decreased in liver failure

47

Serum Amylase

60-160 U/dl c or 111-296 U/L SI

elevated in acute pancreatitis or obstruction
decreased in liver cirrhosis or chronic pancreatitis

48

Anechoic

sonolucent - black - echo free

The structure is fluid filled and transmits sound easily

Better to use harmonics (THI

Veins, arteries, cysts

49

Hyperechoic - echogenic

brighter

reflects sound with a brighter intensity

kidneys, gallbladder

50

Hypoechoic

Darker

used in relation to other structures to describe low level echoes within a structure

51

Enhancement

sound that travels through a cystic substance and it not attenuated

An increase in reflection amplitude from reflectors that lie behind a weak attenuating structure

Increased through transmission

Enhancement looks bright like silver lining on a cloud

Anything fluid will enhance

52

Shadowing

loss of a signal as a result of a strongly attenuating structure

occurs when the sound beam is attenuated by a solid or calcified object

dark shadow

Anything solid will shadow

53

Fluid level

The interface between two fluids that have different acoustic characteristics

Fluid level changes with patient position

54

Heterogenous

not uniform in texture or composition

tumors - solid & cystic
fibroid
blood clot thrombus

smooth and uneven
testicles
thyroid

55

Infiltrating

usually refers to a diffuse disease process

seen in metastatic disease

malignant brast mass

cross over to other organs

56

Irregular borders

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ill defined borders or borders that are not present

metastatic disease
abscess
thrombus

57

speculation

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finger-like projections reaching out into the tissue

58

Isoechoic

very close to the pattern of normal parenchyma

hard to see because it looks the same

59

Ultrasound criteria fro a cyst/comples/solid

solid / fluid

anechoic - shadowing

complex mixed

enhancement

irregular borders

60

Complex complicated cyst

stuff in it (teeth, hair) mixed

61

Complex lobulated

thin walls

made up of or having lobules

62

Complex loculated cyst

thick walls

divided into compartments by septa

63

Sound

Mechanical osculations that are transmitted by particles in a medium

64

Infrasound

under 25 Hz

65

Audible Sound

25 Hz to 20 kHz

66

Ultrasound

over 20 kHz

67

Transducers

Linear - square
Curved array - curved at top
Sector - pie shape
Vector - pie shape but squared off on top
transrectal - cover
transvaginal - cover it

68

cleaning transducer

wipe with disinfectant spray

69

Care and maintenance of rectal and trans-vaginal transducers

During exam: Apply gel to transducer, cover, apply more gel.

Cleaning: trough machine - easy
otherwise - wear goggles, gloves, mask, and gown to clean and place in cidex for 12 minutes.

70

A-mode

Amplitude mode - used in ophthalmology

Fetal mode

71

B-mode

displays dots by broghtness. Basis of all ultrasound

72

M-mode

Motion mode

73

real-time

watching actual scan

74

Time gain compensation

TGC

alias depth gain, or swept gain compensation

over all gain - whole screen

brightens or darkens the screen

75

Laminar Flow

normal pattern of vessel flow

76

Resistance

Passive force in opposition to another active force

77

Wall filter

Not used in DMS

varies sensitivity of detection

78

Doppler

Detects motion - blood flow & Heart

79

Doppler principal

The Doppler principal is the change in frequency when the motion of laminar of turbulent flow is detected in a vascular structure

80

Doppler Shift

The Doppler shift is the change in frequency of a reflected wave; caused by motion between the reflector and the transducer beam

81

Spectral Wave

The demonstrates the natural flow in the vessel interrogated by pulsed doppler

82

Spectral analysis

analysis of the entire frequency spectrum

83

Color flow Doppler

Velocities are quantified by allocating a pixel to flow toward the the transducer and flow away from the transducer

Positive - Red flowing toward transducer
Negative - blue flow away from from transducer

can flip if needed

84

Aliasing

card image

technical artifact.

It occurs when the frequency change is so large that it exceeds the sampling view and PRF.

occurs when doppler shift exceeds the nyquist limit

FIX - change transducer to higher frequency of change the PFR

85

Nyquist frequency

half of the sampling rate of a discrete signal processing system. It is sometimes known as the folding frequency of a sampling system.

86

Spectral Broading

BAD

This echo is a fill-in of the spectral window

caused by several different velocities showing on screen

bad technique - too much gain

Fix - turn down gain

Can happen when stenosis of vein is present (blockage)

87

Ethical Principles

Morality
Atonomy
Beneficience
Confidentiality
fidelity
Justice
Nonmaleficence
Patemalism
Sanctity of life
Veracity
Respect for property

88

Morality

Utilitarianism
Deontology
Virtue

89

Utilitarianism

Actions are morally correct when the largest group of individuals are positively benefitted

90

Deontology

Rules are always to be followed at all times by all individuals - DO NO HARM

91

Virtue

Combines the above to provide a broader view of issues

92

Autonomy

The right of a person to make decisions free from external pressure

93

Beneficience

All acts must be benificial

94

Confidentiality

You must not disclose the facts relating to your patients care to anyone that is not directly involved in the patient's care

95

Fidelty

Your job is to fulfill you obligations. Don't make promises you cannot keep!

96

Justice

Don't favor one patient over another

97

Nonmaleficence

Promote benevolence - Abstain from harm

98

Paternalism

making decisions without consulting the person affected. Only justified when a lack of action will cause harm

99

Sanctity of Life

Life is the highest good.

Moral: You cannot make life of death decisions for your patient

100

Veracity

Be honest in all aspects of you professional life.

101

Patient Rights

Right to considerate & respectful care
info concerning diagnosis
Part in decision- making
Advance directive - Living will, DNR, DNI
Right to privacy
Consent to treatment

102

Patient Responsibilties

Keep appointments
cancel
accurate & complete history
respect for property of others

103

Good Samaritan Doctrine

To reduce reluctance to help strangers
Fear of legal repercussions - sued for wrong-doing

104

Tort

Laws that govern individual rights in noncriminal actions.

An injury, or damage for which civil action can be brought

intentional and non intentional

105

Intentional Torts

Assault
battery
invasion of privacy
false imprisonment
intentional infliction of emotional distress
fefamation

106

Unintentional Torts

Negligence - failure to perform in a reasonable prudent manner or to fulfill expected standards of care

107

malpractice suites

Legal actions involving negligence by a person engaged in a profession

108

Vicarious Liability

It is possible for one to be liable for negligence they did not commit

Negligence can be imputed or placed upon another.

109

Respondeat Superior

Let the master answer
A superior may be called upon to respond to the actions of the servant
The hospital or physicion who employ a sonographer can be held jointly responsible for the negligent actions of sonographer

110

Res Ipsa Loquitur

The thing speaks for itself
Defendants are required to prove innocence
considered guilty until proven innocent

111

Protection against lawsuits

Sonographers are personally liable for any harm a patient suffers as a result of their own actions

Many professionals carry their own malpractice insurance

112

Jurisdiction

Medical professionals live two kingdoms, a single state and the united states

In event of claim of negligence sonographer may be sued in state or federal court

Usually claimant will sue in state where injury occured.

113

Standard of Care

In medical negligence and malpractice cases, standard of care is applied to measure the competence of individual

The traditionally recognized standard of care requires that the medical professional practice his or her profession with the average degree of skill, care, and diligence exercised by members of the same profession practicing in same or similar locality

114

Educational Standard

Standard recognized by profession as appropriate for the field

Educational standard should be met by all those practicing the field

115

Professional Standard

Standard reviewed to determine the appropriate professional practice generally recognized by discipline's national professional organization

Professionals who become stagnant or refuse to change the way they practice may be personally liable if they fail to meet the recommended standards of the profession

116

Malpractice insurance

Wrongful/negligence act that injures a patient

for civil cases

Deep pockets

May not cover intentional acts

117

Informed consent

Patient must be totally informed

all aspects of procedures
potential risks
potential benefits
alternative procedures

Who is responsible for consent?

118

Simple consent

Expressed
Implied

119

Inadequate consent

ignorant consent

120

Medical Records & Documentation

To transmit information about the patient from one health care worker to another

to protect against errors

provide info for medical research

information/protection in case of litigation

Help provide quality assurance

121

Health Care Delivery

3rd party
managed care
governmental -

medicare - old people
medicaid - poor people

122

Pythagoras

Greek 500 BC

noticed a relationship between pitch and frequency

created the sonometer

123

Archytas of Tarentum

Greek 400 BC

Deduced that sound is produced by the motion of on object striking another

Swift motion = high pitch
Slow motion = low picth

124

Aristotle

350 BC

sound is carried through air

125

Boethius

Roman

sound waves were comparable to waves in water

126

Leonardo da Vinci

1500

angle of reflection is equal to angle of incidence

127

Galileo

1638

Frequency of sound determines pitch

128

Sir Isaac Newton

Late 1600's

Theory of velocity

129

Lord Rayleigh

British scientist 1877

1877 published "Theory of sound"

Describes the sound wave as a mathematical equation

130

Lazzaro Spallanzani

Italian priest-scientist 1794

studies with bats

131

Sir Francis Galton

invention of ultrasonic whistle

Galton whistle

132

Christian Johann Doppler

1845

effect of motion on pitch

133

Jacques & Pierre Curie

1880

Piezoelectricity

Discovered that electric potential was produced when a mechanical stress was exerted on a quartz crystal

transducers

134

Paul Langevin

1915-1917

French Scientist

used echoing sound waves to determine underwater objects

Surveillance

realized there was a biological effect

135

G. W. Pierce

1938

converted high frequency into audible sound

136

Floyd Firestone

used ultrasound for metallic flaw detection & cleaning

-Military - ships, battle tanks

137

Robert Wood and Alfred Loomis

1927

examined injurious nature of high doses of ultrasonic energy

cavitation
mechanical stress
localized heating

examined therapeutic nature of lower doses

138

George Ludwig

1947 - 1949

Naval Medical research institute
used ultrasound to detect gall stones
Birth of diagnostic Medical SOnography

139

Ian Donald

Father of obstetrical ultrasound

perfected A-mode measurement of Biparietal diameter for fetal age, weight & growth rate

First to demonstration a fetal gestational sac - 1954

Fluid filled bladder technique for trans-abdominal pelvic ultrasound

140

Carl Hertz & Inge Edler

1954 in Sweden

Used A-mode & B-mode to identify intracardiac structures

echocardiography is born

141

Claude Joyner + John Reid + Howry & Holmes

First Echocardiography equipment

142

Arvo Oksala

Opthalmic ultrasound using A-mode

143

Gilbert Baum

Opthalmic ultrasound using B-mode

144

Rokuru Uchida & Dr. S. Oka

Japan 1950's Lithotripsy device

145

Donald Baker & Dennis Watkins

University of Washington 1966

Developed pulsed Doppler

146

William Fry & Francis Fry

Surgical use of ultrasound using multiple paths to destroy tissue at the intersections without damage to surrounding tissue

147

Future of Ultrasound Medicine

better and better resolutions
smaller and smaller machines
smaller transducers

148

Future of Ultrasound Medicine

Endo Imaging

Endo Cavitary
-endovaginal
-endorectal
-transesophageal

Endovascular
Contrast imaging

149

contrast media

to increase the refraction and reflection of the ultrasonic wave

mostly for cardio

150

Radiographic Technology

mammography
Floroscopy

151

Radiation Therapy

radiation

152

Nuclear Medicine Technology

Check for function

153

Computerized Axial Tomography

CAT scan

Xray slices

comprehensive

154

Magnetic Resonance Imaging

DO not go in MRI room!!

155

Positron Emission Tomography

Check for cancer